Nursing homes'quality and variations in state regulations Quality of care in nursing homes has been of concern for many years and continues to be of concern despite recent reforms implemented by the Centers for Medicare &Medicaid Services (CMS) - reforms of the regulatory oversight process and the publication of nursing home quality report cards on the web. The objective of this project is to contribute to the knowledge base regarding factors influencing quality of nursing home care by examining the relationships between aspects of state regulations (the "state survey" process and civil monetary penalties) and several dimensions of quality. The specific aims are to test the hypotheses that the stirngency of the state regulatory process is associated with 1) clinical quality measured by risk- adjusted health outcomes;2) staffing;and 3) quality of hotel services. This study will bridge a gap in the extant literature on the determinants of high quality nursing home care. The study will combine data obtained from a survey of state licensure offices, the Minimum Data Set (MDS), the Medicare Denominator file, and several other sources including the U.S. Census, the Bureau of Labor Statistics, and the General Accountability Office (GAO). Statistical regression techniques will be used to test the hypotheses that specific aspects of the state survey and enforcement process are associated with quality of care. Instrumental variable techniques will be used to address the potential endogeneity of quality and quality regulation. The public health implications of this study derive from the role of the information and knowledge developed by it. This study will inform state and federal policy reform efforts targeted at regulation and enforcement policies designed to promote high quality of care in nursing homes, which provide care to one of the most vulnerable segments of the U.S. population.